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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (RS / 4-03) '
Prescn�ed by Departmem of Local Gtivemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the CountyAuditor o) the counry where the property is locarea. —
Filing Dafes: 1J Real Property: During the 12 months be%re May 11 o/the yearthe deduction is to 6e elfective.AP�� ��nn�
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduc i s C+��ective.
See reverse side for additional instructions and quali�cations.
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A licant (owner or confract buyer - see restnctions on reverse ide)
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Taui Distrid Key number / legal description Record number
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Assessed value of real property as of MoRgage / Contred indebtedness unpaid as of Is the applicant the ole legal or equitable
March 1, curcent year March 1, current year ��4, 2�� owner? es ❑ No
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/ 3o�oa
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the roperty in question:
�I Properfy ❑ Mobile Home QC 61.1-�
e of mortgagee or contract selier
Address of mortgagee or contracl seller (number and street, city, state, ZIP
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Name of assignee or other owner or holder ortgage
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Address of assignee (number and street, city, sfate, ZIP code)
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Does appliwnt own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for current year? � Yes 0 No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �_ 20 Q'1 20 d i� 20 20 20 20
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Signature County Auditor Date
Ne ceAify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
a sident of Indiana and owner of the aforementioned property on March 1, 20
S� u e(owners ll name) Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07
Fu r ident address o applicant Address of authorized person